complaint·April 21, 2026

Facility staff denied any falls had occurred. Responsible party set up a meeting with physician and an X-Ray was ordered. On June 06, 2025, the X-Ray revealed a displaced femur fracture and resident was transported to the hospital and scheduled for surgery. When family spoke to a physician assistant, they were told the fracture R1 sustained most likely resulted from a mechanical fall. On June 06, 2025, upon hospitalization, R1 was noted to have two wounds, one on the groin and the other on the right heel that had not been reported or documented by facility staff. Interviews with staff revealed it is unclear how R1 sustained a fracture while in care and the facility has no reported record of the resident falling. Four out of four staff, Director of Nursing and Administrator all deny R1 had a fall resulting in the fracture. Staff state all falls are reported and R1 had falls in the past which were reported. Staff stated they had difficulty with transfers due to the resident’s weight and the resident would require 2-3 staff for transfers. Staff 1 (S1) indicates reporting to family by text on June 04, 2025, that the resident’s knee appeared swollen. Facility did not subsequently follow up on the resident’s swollen knee nor seek medical attention. The Department reviewed R1’s medical records for June 06, 2025, through June 23, 2025. Records showed hospital documented “Suspected elder neglect” saying there is a community acquired pressure related deep tissue injury in the right heel which was discovered during admission. Resident was diagnosed with a right knee periprosthetic fracture. The treatment plan indicates R1 was to be admitted for orth opedic surgical stabilization, pain management, medical management, postoperative physical therapy and orthopedic aftercare. Per National Institute of Health (NIH), “This type of distal femur “periprosthetic” (the area immediately around an artificial body part (prosthesis or implant) fracture is usually caused by significant force on a vulnerable bone around a knee replacement, most commonly from a fall or twisting injury.” Upon Department review of records, there is no documentation of severe osteoporosis for R1 or any other condition that would, on its own, cause a fracture of this nature to occur spontaneously without trauma. NIH indicates common reasons for a fracture of this sort would be a fall directly onto the knee or onto the side with the knee twisting, a forceful twisting of the leg during transfers or major trauma such as a car accident. During staff interviews it was reported that the resident’s weight could be a reason for the fracture. However, NIH states that there would need to be significant force for this type of fracture and some sort of physical fall would almost always be involved. CONTINUED ON LIC 9099C DATED 04/21/2026 Based on the information provided such as the physician’s report, medical history information, and medical records, it was determined that the periprostatic fracture is likely to have occurred by a fall or a significant twist and not due to the resident’s weight. The preponderance of evidence standard has been met. Therefore, the allegation is deemed SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8 is being cited on the attached LIC 9099D. A Civil Penalty is pending determination by Community Care Licensing Division as per H&S Code 1569.49(f). An exit interview was conducted with Administrator and a copy of this report along with the Appeal Rights were provided at the time of this visit. incident on September 06, 2025, indicating that the resident had a swollen knee which resulted in the fracture. Facility indicated in the report that the fracture was due to the resident’s weight and not a fall. The report indicates there was no bruising, however the medical records show the resident had swelling and bruising on right knee and thigh. Records reviewed could not confirm when the fall occurred thus the Department is unable to determine if the authorized representative was notified timely or if medical attention was sought timely. Based on record review and interviews conducted, the Department is unable to corroborate the allegations. Therefore, the allegations are deemed unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted with Administrator, and a copy of this report was provided to facility.